Sunday, April 14, 2024

How To Get Insurance To Cover Revision Bariatric Surgery

Gastric Sleeve Insurance Requirements

My Steps from Consultation to Insurance Approval for Bariatric Surgery | #vsg #gastricsleeve

Every insurance provider will have different requirements and criteria to be approved for insurance coverage. Most insurance providers have similar requirements, although it is best to check your individual coverage by contacting your insurance provider. For gastric sleeve surgery most insurance companies require the following:

  • Body Mass Index of 40 or above
  • A body mass index over 35 with at least one comorbidity related to obesity
  • Must have documentation in your medical records confirming that previous attempts at medical treatment for obesity have been unsuccessful

How To Contact Blue Cross Blue Shield Of Florida

Blue Cross Blue Shield of Florida can be contacted via email or telephone. Please be mindful that the contact number may be different depending on the type of plan you have. The best number to reach a representative for assistance is typically listed on the reverse side of your insurance card. For other contact options:

How Much Weight Can You Lose With Bypass Revision

When a patient undergoes a revision to his or her gastric bypass, we usually see a 65-75% excess body weight loss, which is 65-75 lbs weight loss for every 100 lbs. If a patient has a small stomach pouch which cannot be revised, weight loss is usually 50-55 lbs for every 100 lbs of excess body weight.

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How To Know If Revision Surgery Is Right For You

The decision to have gastric bypass revision surgery is not something to be taken lightly.

Before you have revision surgery you will need to rule out any causes of weight regain, inadequate weight loss, and/or adverse side effects.

You will need to do a thorough assessment of your diet and lifestyle to ensure that these are not factors contributing to your undesired results. You will likely have to try diet and modifications before being approved for surgery.

Once diet and lifestyle factors are ruled out, your doctor will perform a series of tests and scans to determine if there is a physical cause preventing you from losing weight or causing adverse side effects.

Once all assessments are complete your doctor will then determine if you are a good candidate for revision surgery.

Why Should You Consider Revision Surgery

Does Texas Require Insurance To Cover Weight Loss Surgery

There are two primary reasons to consider revision surgery

  • If you are not satisfied with the results of primary gastric bypass.
  • Examples of this include

  • If you experience significant side effects from your original surgery
    • Dumping Syndrome
  • If you have experienced some weight loss but still are suffering from obesity-related diseases or morbid obesity
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    Potential Causes Of Post

    • Enlarged Stoma: This is the opening between the stomach and the intestines. Gastric bypass not only creates a smaller stomach, but should also make the stoma smaller, making it harder for food to pass through.
    • Too Much Absorption: Another aspect to the function of a bypass is malabsorption of calories. If this is not sufficient, you will continue to take in excessive calories and gain weight.
    • Large Pouch: If your stomach pouch isnt made small enough, it will be able to accommodate too much food, allowing food to be stored for longer and the calories absorbed.
    • Gastro Fistula: With this, a fissure develops that allows the stomach and intestine to connect outside of the surgical bypass.
    • Poor Lifestyle: Out of all the options, this is the most common. If you do not eat healthier, portion control, and exercise regularly, you will gain weight.

    Can Health Insurance Cover Surgery For Weight Loss

    Health insurance can cover weight loss surgery however, its not a guarantee. Insurance cover for weight reduction surgery is different depending on the insurance policy. However, the majority of insurance policies allow bariatric surgery, provided that the patient meets the criteria for eligibility,

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    Past Attempted Weight Loss

    In most cases, insurance companies require that your patient has made sufficient efforts to lose weight before theyll approve coverage for bariatric surgery. This can include completing a medically supervised weight-loss plan developed by the insurance provider or making other efforts to lose weight as recommended by a doctor. Generally, insurers require the program or efforts to last from three to seven consecutive months.

    If your patient has been unsuccessful in their weight-loss efforts after this period, they may then be considered a candidate for bariatric surgery. You will likely need to provide documentation of the attempts to lose weight, including dietary and exercise regimens, to gain insurance approval.

    How Much Does Weight

    Insurance and Other Payment Options for Bariatric Surgery

    The average bariatric surgery costs $17,000 to $26,000, according to the ASMBS. Mounting evidence shows that surgery for morbid obesity can be more cost-effective than treating the conditions resulting from obesity. However, even with your doctors recommendation, your health insurance might not pay for the surgery.

    The exact cost differs by surgery, circumstances and potential complications. However, ASMBS estimated that the surgery usually leads to lower health care costs and improved worker productivity, which are reasons why health plans usually approve the surgery if you qualify.

    Some insurance companies may require you to complete a 6-month weight-loss program before they agree to cover your bariatric surgery.

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    What States Have Insurance Companies Required To Cover The Cost Of Weight Loss Surgery

    As previously mentioned, around half of states in the U.S. require ACA-compliant health plans to cover weight-loss surgeries for patients eligible to undergo these procedures.

    This does not apply to private health insurance plans or group health insurance plans. These 23 states offer weight-loss surgery in their Essential Health Benefit in all Marketplace health plans:

    Get Partial Coverage If Your Plan Doesnt Cover It

    SECTION SUMMARY:

    • You can get most of the pre-op services paid for

    If you have insurance but it doesnt cover bariatric surgery, youll probably be able to get some of your expenses covered.

    According to several surgical practices we interviewed during our Annual Weight Loss Surgery Cost Survey, its all about how your doctor and hospital submit your claimsto your insurance company. As long as your doctor files the claim using a covered “CPT Code” , then your insurance company will likely cover it as long as the code used accurately reflects the treatmentprovided.

    For example, there are many non-bariatric surgery reasons for your doctor to recommend:

    • Medically supervised diet program

    Regardless of who pays, each of these are also essential steps required before your surgeon will perform your surgery.

    If your surgeon or primary care physician submits the above claims using a weight loss surgery CPT code, your insurance is unlikely to cover it.

    However, if your doctor submits the above claims using a NON-weight loss surgery CPT code, the claims will likely be considered covered benefits.

    While this may sound “sneaky”, in actuality it is a very ethical practice. Services like those listed above are performed as a result of an existing medical condition some are exploratory and intended to accurately diagnose the patient,others are treatments intended to improve the patients health.

    • Self-pay & other discounts
    • Shop different hospitals with the same surgeon

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    Getting Your Health Insurance To Pay For Weight Loss Surgery

    Just because your health insurance policy reflects they cover certain types of bariatric surgery, doesnt mean it will be easy for you to utilize it.

    Be Prepared

    Usually obtaining a pre-approval from the insurance company requires a good amount of paperwork. Each company has its own requirements as well as the definition of medically necessary when considering a patient a qualified candidate.

    Most insurance companies require documented proof of medically-supervised weight-loss attempts and do not consider weight watchers or other such programs adequate.

    Working with an experienced bariatric surgeon will help you navigate through this process. Most bariatric specialists feel that advocating for their patients is an integral part of the responsibility that comes with being a surgeon and they will work diligently to help you.

    It is important to have a good understanding of what your insurance policy covers and expects so you can successfully receive approval.

    Be Persistent

    According to the American Society of Metabolic and Bariatric Surgery, one of the top reasons that patients do not have bariatric surgery is because they are denied coverage.

    Apparently, for about 25% of the patients attempting to utilize their coverage, it is an uphill struggle and they are denied 3 times before obtaining approval.

    Gastric Sleeve Insurance Coverage: Criteria Varies By Insurer

    Does Texas Require Insurance To Cover Weight Loss Surgery

    Insurance providers cover the cost of gastric sleeve surgeries if you meet specific criteria that vary from company to company. Many insurance companies or employers who offer insurance for gastric sleeve surgeries coverage require the body mass index at or higher than 40 for gastric sleeve surgeries or a BMI greater than 35.

    Suppose severe medical conditions are linked to your weight, such as hypertension, type 2 diabetes, sleep apnea, or heart disease. A BMI over 40 is equivalent to approximately 100 pounds overweight for men and 80 pounds overweight for women.

    Variations in gastric sleeves insurance coverage are typical. Some insurer will cover the cost of gastric surgery for those who have a BMI of 40 or more or a BMI between 35 39.9 or one other obesity-related condition while other insurance companies have much more hefty BMI requirements because they havent modified their requirements to cover the gastric sleeve in an independent bariatric surgery that is the primary procedure.

    For instance, Blue Cross-Blue Shield Arkansas requires a BMI of 60 or greater for coverage for gastric sleeve surgeries. If someone has severe lung or heart issues connected with obesity, they could lower the BMI requirement and pay for the cost of gastric sleeve surgery.

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    Private Insurers For Gastric Bypass Surgery

    As for private insurers, each company has its own policy on weight loss surgery. The general rule of thumb is that coverage is available for individuals who have a BMI of 40 or higher, or a BMI of 35 or more, together with a weight-related illness.Companies with more than a few hundred employees are more likely to offer coverage for this type of surgery. Individuals who work for smaller companies with only 100 or so employees are less likely to get insurance for their surgery. Talk to the human resources department of your company to get a better understanding of how much financial assistance is available to you.Another point to remember is that most private insurance companies dont approve bariatric surgeries easily they have requirements that people must meet in order to be eligible. Some insurers ask you to provide a letter that details the medical necessity of the procedure written by your primary care physician, together with documentation of any weight-related ailments you have.Get familiar with your insurers appeals policy when youre doing research on the financial aspects of your surgery. If your insurer turns you down, you can always appeal. You can also talk to the bariatric program about financing options, but be aware that not all of these options will cover you in the event of post-operative complications.

    • BARIATRIC ARTICLES & INFO

    Life after Weight Loss Surgery

    Is Gastric Bypass Revision Worth

    The answer is almost always a resounding YES, but the truth of the matter is the patient needs to do their part for success, along with the surgeon and as a team, the patient can achieve their goal, and if this does not happen, then a revision surgery can help the patient get back on track and reach their goal.

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    Does Health Insurance Cover Weight Loss Surgery

    In many cases, health insurance will cover weight loss surgery, but its not guaranteed. Insurance coverage for weight loss surgery varies with insurance policies. However, most insurance policies will cover bariatric surgery, assuming that the patient meets the qualification requirements, according to Dr. Garber. In addition, insurance eligibility for weight loss changes often, so Dr. Garber recommends working with your insurance provider and your bariatric surgeon to determine if surgery will be covered.

    Second Weight Loss Procedure

    Does your Insurance cover Bariatric Surgery?

    There are two types of second weight loss surgical procedures:

  • Conversion Surgery: surgery to change from one type of bariatric procedure to a different procedure. There only two procedures that can be converted: lap band to gastric sleeve or gastric sleeve to gastric bypass. Both are then permanent.
  • Revisional Surgery: surgery to restore the effectiveness of the original bariatric procedure. Any procedure to treat failed weight loss for the gastric bypass or gastric sleeve is considered revisional surgery.
  • Revisional surgery options are currently considered investigational or experimental by insurance providers. Some types of revisional procedures are:

    • Stoma plication

    A second operation may not be covered by your insurance plan. You will need to review your plan for your coverage information and the requirements that are necessary to be considered for a another weight loss procedure.

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    What Do I Do If My Insurance Does Not Cover Bariatric Surgery

    If you want to have a procedure like endoscopic sleeve gastroplasty that is currently not covered by health insurance, you do have options.

    Most bariatric surgeons work with companies that offer medical loans to help patients finance necessary surgery. IBI Healthcare offers flexible financing options, and some of them require no payments in the first 3-6 months. It may also be possible to offset costs using an FSA or HSA account.

    Additional alternatives may include:

    Free Insurance Check & Cost Quote

    SECTION SUMMARY:

    • You can ask a local bariatric practice for a free insurance check or cost quote
    • You can attend a free in-person seminar or an online webinar offered by a local weight loss surgeon
    • You should schedule a phone or in-person consultation , if you are interested in learning more about weight loss surgery

    Search the weight loss surgeon directory below to find a weight loss surgeon by country and region:

    Do You Qualify for a Bariatric Procedure?

    Patients who qualify for bariatric surgery usually:

    • Are at least 80 lbs overweight
    • Are between 18 and 75 years old
    • Have a history of failed weight loss attempts
    • Thoroughly understand that the procedure is just a tool long-term success requires significant diet and lifestyle changes

    The minimum bariatric surgery qualifications include:

    • A body mass index of 40 or more
    • OR a BMI between 30 and 39.9 with a serious obesity-related health problem like diabetes, high blood pressure, sleep apnea, high cholesterol, joint problems, or others
    • OR a BMI of 30 to 40 with or without health issues for the gastric balloon procedure

    To calculate your BMI, enter your height and weight into the tool, then click the Calculate BMI button.

    Check My Insurance Tool

    Bariatric surgery insurance coverage varies by insurance policy:

    Individual/Family Plans & Small Group Plans Coverage varies by state coverage is required by the Affordable Care Act in some states

    Medicare and Medicaid Bariatric surgery is covered

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    Why Insurance Should Cover Endoscopic Sleeve Gastroplasty

    Currently, insurance plans do not cover endoscopic sleeve gastroplasty , but they should! ESG has gained notoriety over the past several years for being just as effective as gastric sleeve surgery with fewer complications because there are no incisions. In July 2022 ESG became FDA approved and it is likely that in the future it will be covered by insurance plans. Learn more in the official press release.

    Complications from surgery translate into increased medical costs to address the complications. Gastric sleeve surgery has an associated complication rate of 13% which is far higher than the 2% related to endoscopic sleeve gastroplasty .

    Does Insurance Cover Weight Loss Surgery

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    Some but not all insurance carriers cover some types of weight loss surgery but each company has different requirements and limitations. Even if a patients body mass index classifies them as morbidly obese, does not necessarily mean their insurance will approve bariatric surgery. Bariatric surgery is not automatically covered for every person by every carrier just because their BMI number is high. According to the Mayo Clinic, individuals who are most often considered candidates for bariatric surgery:

    • Have tried losing weight through diet and exercise but have been unsuccessful
    • Have a body mass index of 40+
    • Have a body mass index of at least 35+ and are suffering from obesity-related health issues such as type 2 diabetes, high blood pressure, etc.
    • These are just the basics of the criteria for determining eligibility for weight loss surgery and individuals will need to check with their insurance companies for specifics.

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    Should I Use Insurance Or Cash To Pay For Surgery

    Insurance is typically the best way to go when you are considering weight loss surgery. However, many procedures are not covered by insurance. Historically, gastric sleeves, duodenal switches, mini-gastric bypasses and other experimental procedures are not covered. Today gastric sleeves, laparoscopic gastric bypass and lap gastric bands are typically covered by most major insurance companies. But this doesnt necessarily mean your policy includes coverage.

    It depends on your policy not the insurance carrier.

    While most insurance carriers offer some sort of weight loss surgery coverage, your individual policy details whats included and whats not. Some policies specifically exclude weight loss surgery. Most insurance companies charge more to include weight loss surgery coverage. For this reason, you will want to check your policy to see if you have coverage. The best way to do that is to call your carrier directly .

    You can also call a couple of local bariatric surgeons and their staff will check to see if you have coverage. Use our surgeon finder to find a bariatric program in your area.

    Youre covered!

    If you have coverage, then its time to find a surgeon. We recommend attending a couple of seminars and meeting with at least two different bariatric surgeons. This article will walk you through choosing a great bariatric surgeon.

    I dont have coverage.

  • Consider a job with amazing benefits. Yes, in some cases it may make sense to look for a new job just for the benefits.
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